27 Chapter 3 Answers to Research Questions This chapter serves to evaluate the literature and answer the following research questions: 1. To what extent are education requirements and practices changing the focus of occupational therapy? 2. To what extent are public or occupational therapy student perceptions of mental illness affecting the use of occupational therapy as a therapeutic modality? 3. To what extent are there incentives or disincentives that have led occupational therapists to choose other fields of practice? 4. To what extent are current mental health policies changing the use of occupational therapy in treatment for the mentally ill? 5. To what extent are current insurance systems affecting the use of occupational therapy in treating the mentally ill? Answers to Research Questions To what extent are education requirements and practices changing the focus of Occupational Therapy? The Fieldwork I and Fieldwork II information is difficult to compare due to the lack of informative studies on Fieldwork I settings. Most studies found and referenced in this study were regarding the Fieldwork II setting, only the study by Penny (2001) included information specific to Fieldwork I settings, while the others 28 were primarily concerned with Fieldwork II experiences or the setting was not indicated (Lyons and Ziviani, 1995; Sabari, 1985). Education and fieldwork have both been shown to be important factors in the socialization of new OT students in their new roles as emerging practitioners (Penny, 2001; Sabari, 1985). Current educational and fieldwork standards set by ACOTE do not require students to take on high levels of mental health fieldwork or coursework and by doing so, may not allow them to become fully socialized into the area (AOTA, 1998). Students who have not been exposed long enough to the socializing factors in mental health may find it harder to retain the changes in values and ideas that have been a part of their socialization. Penny’s study showed that student ideas about mental health could be changed through positive fieldwork experiences, but without a continued presence of socializing factors the lack of required mental health education and fieldwork may deter students from pursuing a career in this area of OT practice. Fieldwork I experiences were found to negatively impact OT students in their attitudes towards people with mental illness, while Fieldwork II experiences and coursework were found to help promote more positive attitudes (Penny, 2001). The findings indicated that this was due to socialization to the profession allowed in the Fieldwork I setting and then socialization towards mental health practice ideas in Fieldwork II and the coursework settings. The time frame for Fieldwork I is not long enough to allow for both socialization in the professional setting and in the mental health area. This can be seen in Lyons and Ziviani’s study (1995), where it was indicated that students found the time given too short to acclimate to the setting and overcome their anxiety. 29 Students in similar settings but in different pre-professional programs such as nursing students and medical students were found to have similar reactions in their socialization to mental health areas as OT students did (Kramer cited in Scott, 1990). These reactions consisted of anxiety when put into the mental health setting and progressing through socialization processes as they entered the fieldwork settings and the professional arena. This is obviously not limited to only OT students and seems to be a common reaction to fieldwork placements. Even students who had specifically chosen mental health areas such as psychiatric residents were found to have similar reactions to their fieldwork placements (Bucher, 1969). To what extent are public and occupational therapy student perceptions of mental illness affecting the use of occupational therapy as a therapeutic modality? In this portion of the literature review we have seen that as we progress in medical science, the understanding of mental illness is increasing and the public perception of mental illness is gradually improving (Durand and Barlow, 2003). Even with these improvements, student and public perceptions of mental illness are still negative. The stigma and stereotypes that we impart to the young carry well on into adult and professional life as we can see in the research gathered about students going into mental health areas. Many students going into mental health areas, not just OTs, but psychiatric students are affected as well. Their anxiety at working in these areas and some of the reasoning behind the anxiety are a result of the stigma our culture perceives around mental illness. 30 Our culture is still working to dispel the stigma of mental illness (Durand and Barlow, 2003). As evidenced by the studies in the public perceptions section, some of this stigma is so interwoven into our culture as being an acceptable idea that we do not notice the allusions to mental illness that continue to quietly perpetuate the stigma (Clarke, 2004; Whal, 2003). People hear the phrases “are you crazy” and “have you lost your mind” and don’t bat an eye. We shrug them off without realizing the negative message these phrases are sending out, telling others that something is wrong with having a mental illness. These ideas about mental illness are presented in early childhood, not only through family but through media as well, and continue on well into adulthood (Clarke, 2003; Whal, 2003). Research directed towards OT student perceptions of mental illness has revealed that OT students still have negative perceptions of people with mental illness (Lyons and Hayes, 1993). Lyons and Hayes (1993) found differences in the perceptions of OT students and business students, with OT students desiring less social distance than business students, but remarked that this was different than past studies that had been included as background. Even with this finding OT students did not rank mental illness differently than business students in terms of desirability. This is not surprising considering the stigma that surrounds mental illness. Lyons and Ziviani (1995) found that students had high levels of anxiety when starting fieldwork in mental health care settings. Some of the major concerns were for personal safety and concern about the unpredictability of patient behavior. These results were not limited to only OT students. Other students, even those in mental health areas were subject to similar stigma. Bucher (1964) and 31 Kramer (1974) found similar results for nursing students, medical students and psychiatric residents. Outside of these studies, few dealt specifically with OT student perceptions of mental health. Of the studies examined, the researchers do not focus on why the stigma is present, only that it is present and how it affects the fieldwork and perceptions of OT students. To what extent are there incentives or disincentives that have led occupational therapists to choose other fields of practice? From the areas researched as possible incentive and disincentives few if any of the areas were found to be incentives to tempt OTs into mental health practice. Many areas were found to be areas of personal preference, and therefore subject to individual partiality and difficult to generalize as a pattern for all OT practitioners. The lack of recognition of OTs as mental health professionals was found to negatively impact the recruitment and retention of OTs in the mental health field (Glomstad, 2004). The lack of recognition is compounded by the absence of opportunity for OTs to specialize within mental health areas. With the lack of recognition and the lack of opportunity to specialize in this area, OTs do not have a strong claim to professional jurisdiction. Abbot (1988) defined professional jurisdiction as a legitimate claim to expertise in a professional area. Without a legitimate and strong claim to mental health practice OTs cannot continue to expect recognition in this area of practice. 32 Compounding the difficulties posed by the weak claims of professional jurisdiction by OTs in mental health is the relatively undefined role of OTs as mental health practitioners (Price, 1993). If a profession itself is unable to define its practice in specialty areas, it is difficult for other professions to cede their claim on authority in a given area. Creek (1998) alludes to the idea of professional jurisdiction in her references to boundary disputes, stating that “without a language of occupational therapy, it is difficult to define boundaries and defend territory.” The psychiatric profession has a more defined language and treatments, so they are more able to defend their position of professional jurisdiction in mental health areas. An area that can be interpreted as either advantageous or disadvantageous for OT practitioners is personality traits. Brollier (1970) found that OT mental health practice appeals to a specific subcategory of OTs. These OTs score higher on dominance and autonomy than other OTs. The high levels of autonomy and dominance make sense when considered with the lack of definition in practice area for mental health OTs and the difficulties presented in mental health practice. In the same study Brollier found corresponding evidence that physical disability OTs scored lower on dominance and authority, but higher in order and deference, suggesting that OTs who desire more order and direction in their role will gravitate away from mental health practice. Compensation can also be seen in a positive or negative light. Mental health OT’s were found to make just slightly less than the average salary for all OTs (Brown, 2003). While this is not bad, if compensation is an area of value to a prospective employee, they may seek out higher paying or less stressful situations of 33 employment. To add to the difficulties of lower compensation for mental health OTs is the fact that OTs who hold certificates of specialization, such as in pediatrics, hand therapy, or neurology, were found to make $5000 to $10000 more annually than those without. This can add considerably to the allure of areas outside of mental health. Burnout is a common occurrence in the health care field (Brown and Pranger, 1992). Burnout was found to be an area that had a decidedly negative impact on OTs in mental health areas. The loss of idealism and purpose that occurs with burnout happens much faster for mental health OTs due to the work conditions in the mental health field. Brown and Pranger (1992) found that levels of involvement, the number of patients in an OT’s caseload with schizophrenia, age, pay levels and time working in the mental health field all contributed to burnout. Sturgess and Poulsen (1983) had similar findings, stating that psychosocial OTs worked more, had larger patient loads and less contact with patients than any other OT specialty area. With these factors coexisting within mental health OT practice, it is hardly surprising that burnout is a common factor in this area. To what extent are current mental health policies changing the use of occupational therapy in treatment for the mentally ill? With the introduction of new psychotherapeutic drugs in the 1950’s and the push towards deinstitutionalization in the 1960’s and 70’s, occupational therapy began to expand into new areas of practice (Peters, 1984). With this expansion, occupational therapists were faced with the changing health care policies that affected 34 the areas of practice and funding. The effects of these changing policies were diverse, some directly affecting the OT, and others changing the mental health care system with less obvious effects on OTs. The Mental Health Parity Act of 1996 and the Paul Wellstone Mental Health Equitable Treatment Act of 2003 changed the way mental health services are addressed by insurance providers. The Mental Health Parity Act required that equal funding and benefits be provided for mental health and medical services (NAMI, 2004). The Paul Wellstone Mental Health Equitable Treatment Act extended the mental illnesses covered under the Mental Health Parity Act, and barred financial limitations on mental health benefits that are different from surgical and medical benefits. These changes to mental health policy do not specifically cover OT services, but do allow for more funding for overall treatment, which includes OT services. The affects of the Garrett Lee Smith Memorial Act also change funding provided for mental health services, and are not directly related to OT services. The act authorizes funding for suicide prevention and for college mental health services (AOTA, 2004b; NMHA, 2004c). The funding is not allocated specifically for OT services, but can be used to create new programs that OTs can be involved in. The Medicare Occupational Therapy Coverage Eligibility Act of 2003 is one of the few policies found that directly impacts OTs. This act has been introduced into congress but has not been passed yet (AOTA, 2004b). This act would make OT services equal to speech and physical therapy services under Medicare Title XVIII. This does not apply specifically to OT mental health services, but all OT services covered under Medicare. 35 To what extent are current insurance systems affecting the use of occupational therapy in treating the mentally ill? The major areas of reimbursement in mental health occupational therapy are Medicare, Medicaid, private health insurance, and HMO/PPO’s. Each system has its own priorities in reimbursing for treatment and their own system for how it all works. Medicare is a federal program and only reimburses for mental health OT services if they are properly documented, given in a designated setting and then only for specific mental illnesses (Lopes, 1998; Peters, 1984). Medicaid is funded federally, but the funds are distributed by the states as they see fit for treatment. Oregon for example has set up the Oregon Health Plan, and under it there are varying tiers of coverage, each covering different levels of treatment for mental illness (OHP, OMAP, DHS 2003). These systems alone are difficult to understand and navigate, given their lack of clearly defined language that delineates specific coverage for OT services, not to mention mental health OT services. An examination of private health insurance and HMO/PPO’s is even less clear. Therapeutic settings and benefits are variable from state to state and plan to plan (Peters, 1984). Some programs are able to charge for costs of mental health OT services by including them in the program or room and board fees, but it is limited (Peters, 1984). With this system in place and no clearly delineated reimbursement plans for OT services, as well as the confusion about OT roles in mental health, OT services in mental health are severely compromised. 36 Summary The following has been illustrated by the analysis of the literature reviewed. Education and Fieldwork have a great effect on reducing stigma and educating students on mental illness and mental health care. There is much research to date involving Fieldwork II opportunities, but little to acknowledge the place of Fieldwork I in the socialization and recruitment of OT students into mental health care. Perceptions of mental illness, despite efforts to change them are still highly negative. They are introduced at an early age and continue on well into adulthood and professional life. There are few true incentives to attract occupational therapists into mental health practice. Many of the incentives and disincentives are subject to personal biases and therefore difficult to apply generally to all occupational therapy practitioners. Most policies affect occupational therapy practice indirectly. They are typically concerned with funding or changing the scope of patients treated by rewording the past policies to be more inclusive. The coverage of mental health care by Medicare, Medicaid, private insurance, and HMO/PPO’s is diverse, and the areas covered are dependent on the provider. Mental health care for occupational therapy is rarely recognized in the literature provided, and therefore difficult to analyze and put into practice by the mental health OT.